Inbound Guest Medical Insurance Benefits

Schedule of Benefits

All coverages and plan costs listed in this brochure are in U.S. Dollar amounts.

Age 14 days to Age 69

Plan A

Plan B

Plan C

Plan D

INPATIENT

$45,000 Max per Injury/Sickness

$65,000 Max per Injury/Sickness

$85,000 Max per Injury/Sickness

$120,000 Max per Injury/Sickness

Hospital Room & Board including miscellaneous

Up to $1260/day, 30 day max

Up to $1565/day, 30 day max

Up to $1785/day, 30 day max

Up to $2340/day, 30 day max

Hospital Intensive Care Unit

Additional $595/day, 8 day max

Additional $720/day, 8 day max

Additional $790/day, 8 day max

Additional $1020/day, 8 day max

Surgical Treatment

Up to $2970

Up to $3960

Up to $4840

Up to $6600

Anesthetist

Up to $740

Up to $990

Up to $1210

Up to $1650

Assistant Surgeon

Up to $740

Up to $990

Up to $1210

Up to $1650

Physician’s Non-Surgical Visits

Up to $50/visit, 1/day, 30 visits max

Up to $65/visit,1/day, 30 visits max

Up to $75/visit, 1/day, 30 visits max

Up to $100/visit, 1/day, 30 visits max

A Consulting Physician, when requested by attending Physician

Up to $405

Up to $465

Up to $485

Up to $600

Private Duty Nurse

Up to $495

Up to $550

Up to $550

Up to $660

Pre-Admission Tests w/in 7 days before Hospital admission

Up to $990

Up to $1100

Up to $1100

Up to $1100

OUTPATIENT

Surgical Treatment

Up to $2970

Up to $3960

Up to $4840

Up to $6600

Anesthetist

Up to $740

Up to $990

Up to $1210

Up to $1650

Assistant Surgeon

Up to $740

Up to $990

Up to $1210

Up to $1650

Physician’s Non-Surgical/Urgent Care Visits

Up to $50/visit, 1/day, 10 visits max

Up to $65/visit, 1/day, 10 visits max

Up to $75/visit, 1/day, 10 visits max

Up to $100/visit, 1/day, 10 visits max

Diagnostic X-rays & Lab Services

Up to $405 - Additional $250 - One Cat scan, PET scan or MRI

Up to $465 – additional $375 - One Cat scan, PET scan or MRI

Up to $485 - Additional $450 - One Cat scan, PET scan or MRI

Up to $600 - Additional $500 - One Cat scan, PET scan or MRI

Hospital Emergency Room (all expenses incurred therein)

Up to $295

Up to $395

Up to $485

Up to $660

Prescription Drugs

Up to $90

Up to $115

Up to $135

Up to $180

Outpatient Surgical Facility

Up to $900

Up to $1030

Up to $1070

Up to $1320

OTHER TREATMENT & SERVICES

Ambulance Services

Up to $450

Up to $450

Up to $450

Up to $450

Initial Orthopedic Prosthesis/brace

Up to $990

Up to $1160

Up to $1240

Up to $1560

Chemotherapy and/or radiation therapy

Up to $990

Up to $1175

Up to $1275

Up to $1620

Dental Treatment for Injury to Sound, Natural Teeth

Up to $550

Up to $550

Up to $550

Up to $550

Mental & Nervous Disorder & Substance Abuse

Same as any Sickness

Same as any Sickness

Same as any Sickness

Same as any Sickness

Physiotherapy

Up to $40/visit, 1/day, 12 visits max

Up to $40/visit, 1/day, 12 visits max

Up to $40/visit, 1/day, 12 visits max

Up to $40/visit, 1/day, 12 visits max

Emergency Evacuation

$50,000

$50,000

$50,000

$50,000

Repatriation of Remains

$7,500

$7,500

$7,500

$7,500

AD&D Principal Sum

$25,000 Common Carrier

$25,000 Common Carrier

$25,000 Common Carrier

$25,000 Common Carrier

If an insured person turn 70 years old during the purchased coverage period, the 70 and over benefit schedule becomes effective upon the day the insured turns 70. Individuals with the $85,000 or $120,000 per injury or sickness policy maximum will receive the $60,000 per injury or sickness schedule for age 70 and older. Individuals with the $45,000 or $65,000 per injury or sickness policy maximum will receive the $40,000 per injury or sickness schedule for age 70 and older.